Article excerpt

How Merck and the WHO have sustained a fragile balance of power in their battle against river blindness

BRENDA COLATRELLA, an executive of the multinational pharmaceutical giant Merck & Co., remembers being stunned at a meeting back in 1996 by a proposal made by a colleague at the World Health Organization (WHO). Since 1987, Merck and the WHO had been partners in an innovative program to eliminate onchocerciasis, a leading cause of blindness in the developing world. Merck's donations of its breakthrough drug Mectizan, with the WHO's technical support, had already saved millions of Africa's poor from the scourge known as "river blindness," using distribution by mobile drug-delivery teams of health professionals from numerous nongovernmental organizations. Though it was an unsustainable method in the long run to treat the estimated 120 million people at risk of contracting the disease across 35 countries,1 it had been quite successful over its first nine years of operation.

But at the 1996 meeting, in Geneva, the WHO's research team was proposing a radical and untested delivery strategy that Colatrella feared could upset the whole effort: to let local communities select their own health workers - usually lay volunteers with unproven capacity and reliability - to distribute the drug and monitor patient care.

To Colatrella's Western sensibilities, the proposal was unfathomable. "It defied every protocol we lived by, starting with the fact that trained physicians administered prescription drugs, lay people did not," she recalls thinking. "I nearly fell off my chair." What if the local, typically illiterate workers improperly dosed the medication, she worried, or failed to accurately record adverse reactions? The Food and Drug Administration, to which Merck ultimately answered as a U.S. company, could pull the plug on the program altogether.

And what if Mectizan seeped into the black market, finding uses it wasn't approved for? Any negative impact on patients' health would be devastating - and surely damage Merck's reputation, turning its good intentions into a PR nightmare. Colatrella glanced across the meeting table at her Merck colleague, Char lie Fettig, then-senior marketing director for anti-infectives. She read his reaction on his face: "No way, José." He later added to her, privately, "This will never fly."

But fly it did. In fact, over the past decade, the WHO's community-directed treatment (CDT) strategy, pioneered by the Mectizan Donation Program (MDP), has become a fixture of mainstream public health delivery throughout the Third World. Moreover, with its free doses of Mectizan to treat and prevent the blindness-causing eye lesions of onchocerciasis, MDP has become one of the most lauded public health achievements of the 20th century for its coverage of an unprecedented number of beneficiaries.2

MDP, starting in 1987, was not only the first program to give away a prescription drug over a sustained period. It also pioneered the now-common cross-sector partnership model that forged standards of cooperation between private enterprise and multiple levels of public organizations. The legendary program has since spawned an entire industry of public-private drug-donation initiatives, from Pfizer's efforts to combat trachoma, to Novartis' work in leprosy, and GlaxoSmithKline's in malaria and lymphatic filariasis.

Yet, for all of the partnership's acclaim, Merck's uncharted journey with the WHO, along with the World Bank and dozens of NGOs and national health ministries, has given rise to a number of conflicts over the last 18 years that could just as easily have shut the program down. How these organizations with radically different experience and motivations found common ground over controversial issues such as CDT is a study in the fragile balance of power sharing. As in any strong partnership, the success of the MDP is rooted in the art of knowing when to exert, cede, or compromise control over critical decisions. …

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